Provider Demographics
NPI:1417278706
Name:MENDEZ, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:MENDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42947 BEAMER CT
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-6625
Mailing Address - Country:US
Mailing Address - Phone:951-855-4967
Mailing Address - Fax:
Practice Address - Street 1:28581 OLD TOWN FRONT ST
Practice Address - Street 2:STE 201
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-2724
Practice Address - Country:US
Practice Address - Phone:951-399-2810
Practice Address - Fax:909-363-9255
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-21
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA715151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health